Genesis
VOICE OF STUDENTS
Myth: silver sulfadiazine is the best treatment for minor burns
It is traditional teaching and practice that silver sulfadia-
zine (SSD) is the agent of choice for the outpatient man-
agement of minor or partial-thickness burns. Published
reports show, however, that other methods of outpatient
burn management are superior. Indeed, it is difficult to
find results of any trial in which SSD is the preferred
treatment.
The American Burn Association defines minor burns,
which require only outpatient management, as one of the
following:
• partial-thickness burns that are less than 15% of the
total body surface area (TBSA) in people 10 to 50
years of age
• partial-thickness burns that are less than 10% TBSA
in children younger than 10 years or adults older than
50 years of age
• full-thickness burns that are less than 2% TBSA in
anyone1
The definition also requires that the patient has no other
injuries.
To determine the optimal method of outpatient burn
care, the clinician must consider the goals of outpatient
burn management: rapid healing, prevention of infection,
patient comfort, compliance, cost, maintaining full func-
tion, and returning the patient to full productivity during
the treatment period.2
Honey, an inexpensive, simple, and natural substance,
has been used since ancient times to treat burn wounds. In
1998, Subrahmanyam randomly assigned 50 patients
with less that 40% TBSA partial-thickness burns to 1 of 2
treatment groups.3 The groups were similar in gender,
mean age, mechanism of injury, and burn surface area.
Twenty-five patients were treated with pure, unprocessed,
undiluted honey, and 25 patients were treated with SSD-
impregnated gauze. Dressings were changed daily, and the
wounds were inspected every 2 days until healed. Biopsy
specimens for analysis and culture were taken from the
wounds on presentation, day 7, and day 21. In the honey-
treated group, 84% of the patients showed clinical granu-
lation and epithelialization of the wound by day 7, and
100% showed such progress by day 21. In the SSD-
treated group, wound healing was evident in 72% by day
7 and in only 84% by day 21, although these differences
were not statistically significant. By day 21, wound healing
was complete in all of the patients in the honey-treated
group and in only 21 of the 25 patients in the SSD-treated
group (p < 0.05).
www.ewjm.com
Results of another study suggest that honey has anti- John Y Chung
..................................................................................................................................................
bacterial properties that are superior to those of SSD.4 Resident physician
Subrahmanyam randomly assigned 104 patients with less Olive View-UCLA
Medical Center
than 40% TBSA partial-thickness burns to 1 of 2 groups. Department of
Fifty-two patients were treated with honey, and 52 pa- Emergency Medicine
tients were treated with SSD. Biopsy specimens for culture Mel E Herbert
and sensitivity determination were taken on admission, Assistant professor of
day 7, and day 21. Honey was superior to SSD cream for medicine
preventing bacterial growth in the burn wound and for UCLA School of
Medicine
wound healing (p = 0.05). Although Subrahmanyam’s Assistant professor of
studies were not conducted in an outpatient setting, and nursing
the TBSA of partial-thickness burns was as much as 40%, UCLA School of
these results suggest that honey may be a simple, inexpen- Nursing
Olive View-UCLA
sive, alternative—and probably superior—dressing to use Medical Center
when treating minor burns. Department of
The use of synthetic alternatives in the treatment of Emergency Medicine
Sylmar, CA 91342
minor burn injuries has been explored. In 1990 Wyatt et
al compared hydrocolloid dressing (Duoderm) to SSD Correspondence to:
cream for the outpatient management of second-degree Dr Herbert
burns.2 Duoderm is a flexible sterile dressing that has an mherbert@ucla.edu
outer layer of polyurethane foam and an inner adhesive
Competing interests:
layer of a hydrocolloid polymer complex. The foam layer
None declared
extends beyond the adhesive hydrocolloid layer, forming a
border that adheres to the skin. Fifty patients with burns West J Med
of less than 15% TBSA, who were evaluated within 24 2001;175:205-206
hours of injury and did not require hospitalization, were
randomly assigned to 1 of 2 groups. The groups were
similar in age, gender, and number of participants. One
group was treated with Duoderm, the other with SSD
cream. The patients were reexamined at least biweekly,
when wound-bed healing, wound-margin healing, pain,
number of dressing changes between visits, and ease of
dressing application and removal were assessed.
At the time of the final evaluation, the burns were
photographed and inspected for appearance of the healed
burn, repigmentation, wound contraction, approximate
time for dressing change, patient compliance, limitation of
activity, and number of days until healing was complete.
Compared with those in the SSD-treated group, burns in
patients treated with Duoderm healed faster, showed bet-
ter appearance after healing and better repigmentation,
required fewer and less elaborate dressing changes, and
were less costly to treat. Treatment with Duoderm was
associated with significantly less limitation of activity
(91% of patients had no limitation with Duoderm vs
45% of patients treated with SSD, p < 0.01), and better
patient compliance (100% compliance with Duoderm vs
85% with SSD). Duoderm was also less expensive when
compared with SSD dressings ($11.30 vs $26.00 for a
Volume 175 September 2001 wjm 205
......................

Genesis

nylon fabric that is mechanically bonded to a thin, Silastic,

semipermeable membrane and coated with collagen poly-
peptides. In a prospective study of 52 patients with partial-
thickness burn wounds less than 24 hours old, Gerding et
al randomly assigned 30 patients to treatment with Bio-
brane and 26 patients to treatment with SSD.5 Wounds
were inspected 24 to 36 hours after initiation of therapy
and twice a week thereafter. Patients with burns treated
with Biobrane healed faster (10.6±>0.8 days vs 15.0±1.2
days, p < 0.001), had less pain, and incurred lower treat-
ment costs.

CONCLUSION
The traditional idea that SSD cream is the first-line treat-
ment for minor burn wounds is archaic. Other methods
are better and more cost effective. Evidence exists that the
use of SSD may place patients at increased a risk of de-
veloping neutropenia, erythema multiforme, crystalluria,

PR Newsire/National Honey Board

and methemoglobinemia.3

Honey prevents bacterial growth and promotes healing of minor burns
1-week supply). In light of these results, Duoderm seems
to be a more effective alternative to SSD for the outpatient
management of minor burns.2
Another membrane-like dressing, Biobrane, is also ef-
fective treatment for minor burn injuries. Biobrane is a
bilayer, semisynthetic dressing composed of knitted-elastic
....................................................................................................
References
1 Schwartz LR. Thermal burns. In: Tintinalli JE, Ruiz E, Krome R, eds.
Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York:
McGraw-Hill; 1996;893-898.
2 Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid
dressing and silver sulfadiazine cream in the outpatient management of
second-degree burns. J Trauma 1990;30:857-865.
3 Subrahmanyam M. A prospective randomised clinical and histological
study of superficial burn wound healing with honey and silver
sulfadiazine. Burns 1998;24:157-161.
4 Subrahmanyam M. Topical application of honey in treatment of burns.
Br J Surg 1991;78:497-498.
5 Gerding RL, Emerman CL, Effron D, Lukens T, Imbembo AL,
Fratianne RB. Outpatient management of partial-thickness burns:
Biobrane versus 1% silver sulfadiazine. Ann Emerg Med
1990;19:121-124.

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